ADITYA JYOT EYE BANK
OnLine - UNIFORM DONOR PLEDGE

In the hope that i may help others, I hereby make this anatomical gift, if medically acceptable to take effect upon my death. The words and marks below indicate desires.
I give my eyes for the purpose of transplantation, medical research or education. I further direct my next-of-kin herein named to execute this gift after my death. I would like my next-of-kin notified of my pledge to donate.

Donor Details
Name
Last Name Middle Name First Name
Address                    
Area City
State Pin Code
Phone No Birth Date / Age
Email Gander
 
Next - Of - Kin
Name
Address
City State Pin
Phone No
 
Physician's Details
Name
Address
City State Pin
Phone No